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The congestive heart failure disease management program had been in effect only a few weeks when the staff at St. Vincent Hospitals and Health Services in Indianapolis began to see a major improvement in care for patients. For example, one patient, a woman in her early 40s, had major issues in self-care for heart failure. She was on disability, had children to support, and couldn’t afford the co-payment for some of her medications. The physicians were not aware of her personal problems until she was enrolled in the heart failure program.
The case manager started calling the woman on a daily basis. She arranged for the health plan to provide a scale and for her employer to use some of its charitable funds to pay for the drug co-payment. She provided the woman with information on managing her disease, such as foods to avoid and the importance of weighing herself. After a month in the program, the woman told the case manager that for the first time in months, she was able to get her shoes on and that she felt like she might be able to return to work.
St. Vincent Hospital and Health Services, St. Francis Health Network, and ADVANTAGE Health Plan began collaborating last spring on a joint disease management program for diabetes and congestive heart failure, two of the most pervasive diseases in Indiana.
It’s much too soon for outcomes data to be available from the program but the anecdotal success stories have convinced Bernard Emkes, MD, medical director at St. Vincent, that the program will be a long-term success. "This is the kind of success we like to see. You need only one or two [cases] like this to pay for the program. And, the patient is enjoying a new level of quality of life that you can’t begin to put a price on," Emkes says.
Here’s how the program works:
The ADVANTAGE Health Plan identified initial patients targeted for the program from retrospective claims review. To help identify new patients, ADVANTAGE includes a questionnaire with 10 key health management questions in its welcome packet for all enrollees. "This allows us to be proactive. Otherwise, we’re running on a three-month claim lag. We don’t even know someone has a condition until [he or she is] hospitalized, and it’s usually three months later because that’s when we get the claims," says Isaac Myers, MD, vice president of Medical Affairs at ADVANTAGE.
If an enrollee or family member is identified with congestive heart failure or diabetes, the system sends a more detailed information sheet, which stratifies the member into four classifications, based on severity. The collected information is sent out to the networks so they can put the member into case management if needed. The two PHOs also have identified and are tracking their own targeted patients. "From our perspective, the system provides a very efficient case management process," Myers says. He foresees decreased admissions and emergency room visits in the future, but the plan is not yet at the point of measuring them.